Localised Unilateral Blepharochalasis

British3JournalofOphthalmology 1994; 78: 881-882 881

CASE REPORTS Br J Ophthalmol: first published as 10.1136/bjo.78.11.881 on 1 November 1994. Downloaded from

Localised unilateral blepharochalasis

R M Manners, J R 0 Collin

In 1807 Beers' described a condition which was later named blepharochalasis (Gk=eyelid slackening) by Fuchs.2 The condition consists of recurrent attacks of oedema of the eyelids and in chronic conditions the skin becomes reddish, thin, and redundant. Periorbital sequelae include ptosis, pseudoepicanthic fold with underlying nasal fat pad atrophy, blepharophimosis, proptosis, lower lid malpositions, lacrimal gland prolapse, and cysts. The peak age of onset is in the teens and twenties with no sex predominance. The attacks of oedema occur with varying frequency during the active/early stage (monthly - annually) and last a few hours to a week or more. They continue for many years but gradually become less frequent until a quiescent/late stage is reached. Unilateral blepharochalasis has been reported to be quite rare.3'5 Histological changes in blepharochalasis include epidermal atrophy, a loss of elastin fibres, and dermal vasculitis with an increase in the size of the vessels and perivascular cuffing. Figure 2 Appearance ofpatient I week postoperatively. We present a case of localised, unilateral blepharochalasis which was confined solely to tion. Medical history was normal with no history the lateral half of the left upper and lower ofatopy. eyelids. On examination during a quiet phase, the http://bjo.bmj.com/ right eye showed no abnormality. The skin overlying the left lateral canthus had a reddish Case report discoloration and was thin, telangiectatic, and A 37-year-old man presented with a history of redundant in the lateral aspect of the upper and episodes of swelling of the lateral half of the left lower eyelids (Fig 1). There was rounding of the upper and lower eyelids which had started in his lateral canthus with marked lateral canthal

Moorfields Eye Hospital, on September 27, 2021 by guest. Protected copyright. City Road, London late teens and recurred initially every 2-3 months tendon laxity. The horizontal palpebral aper- EC1V 2PD but more recently less frequently. The swelling tures measured 29 mm on the right and 25 mm on R M Manners was most prominent in the lateral half of the J R 0 Collin the left. There was no change in the area on eyelids, lasted up to 24 hours, and was generally Correspondence to: Valsalva manouevre. Miss R M Manners. accompanied by a red discoloration ofthe lateral The lateral canthal region was explored under Accepted for publication conjunctiva. The episodes were frequently local anaesthesia via a lower lid blepharoplasty 7 July 1994 associated with an upper respiratory tract infec- approach. No vascular lesion was found. The lateral canthus was reattached to the periosteum of the lateral wall of the orbit using a 5/0 non- absorbable suture. Redundant skin was excised from the lateral half of the lower and upper eyelids and the wound sutured with 6/0 non- absorbable sutures. Examination of the excised skin showed findings consistent with blepharochalasis3 and no evidence of a vascular malformation. The result 6 weeks postoperatively is shown in Figure 2. No attacks of swelling have occurred during the postoperative period.

Comment Figure I Appearance of Lateral canthal tendon laxity has been reported patient preoperatively. to arise in blepharochalasis owing to a dehiscence 882 Manners, Collin

of the tendon from the eyelid tissue.3 This features did not suggest lacrimal gland involve-

produces a rounding of the lateral angle and ment. Br J Ophthalmol: first published as 10.1136/bjo.78.11.881 on 1 November 1994. Downloaded from acquired blepharophimosis. The dark discolora- The diagnosis of blepharochalasis can be, tion over the lateral canthus can precede the difficult ifthe condition is localised or unilateral. tendon dehiscence. Our case shows how characteristic changes in the Blepharochalasis is an uncommon condition skin and periorbita, together with a classic and Brazin commented that its occurrence history and the exclusion of other causes of lid unilaterally was extremely rare.4 This view is swelling, all help in the diagnosis of an atypical supported by Langley et al.5 Collin, however, case ofblepharochalasis. reported a series of 30 cases where 14 cases were unilateral.6 This may reflect the referral pattern ofdiagnostically difficult cases to one centre. 1 Alvis BY. Blepharochalasis. Report of a case. AmJr Ophthalmol 1935; 18: 238-45. No previously reported cases have described a 2 Fuchs E. Ueber Blepharochalasis (Erchlaffung der Lidhaut). localised example of blepharochalasis. Our Wien Klin Wochenschr 1896; 9: 109-10. 3 Custer PL, Tenzel RR, Kowalczyk AP. Blepharochalasis patient had normal skin and periorbita in the syndrome. AmJ Ophthalmol 1985; 99:424-8. medial aspect of the left upper and lower eyelids 4 Brazin SA, Stem LJ, Taylor-Johnson W. Unilateral blepharochalasis. Arch Dermatol 1979; 115: 479-81. which did not require surgery. The main 5 Langley KE, Anderson RL, Patrinely JR, Thiese SM. differential diagnosis in this case was ofa vascular Unilateral blepharochalasis. Ophthalmic Surg 1987; 18: 594-8. lesion but this was excluded at surgery together 6 Collin JRO. Blepharochalasis. A review of 30 cases. Ophthal with other infiltrative lesions. The clinical PlastReconstrSurg 1991; 7: 153-7.

BritishJ3ournalofOphthalmology 1994; 78: 882 Superior oblique myokymia - a topical solution?

Kim Bibby, James S Deane, David Farnworth, John Cappin

Superior oblique myokymia (SOM) is a rare Comment ocular motility disorder characterised by a Superior oblique myokymia was described as a monocular high frequency, low amplitude cyclo- distinct entity by Hoyt and Keane as a benign, torsional tremor. It occurs intermittently, giving periodic uniocular vertical and rotary micro-

rise to sometimes obtrusive symptoms of tremor.' It is rarely associated with serious http://bjo.bmj.com/ oscillopsia and diplopia. underlying pathology, but can be disturbing symptomatically. Susac and Smith report suc- cessful elimination of symptoms with the use of carbamazepine, and go on to advocate superior oblique myotomy for intractable cases, or Case report patients who cannot tolerate the drug.2 Pro-

A 50-year-old woman presented to the eye pranolol is cited as a pharmacological alternative on September 27, 2021 by guest. Protected copyright. casualty department, Leicester Royal Infirmary by Tyler and Ruiz.3 with a 13-month history. She described Leigh et al describe success with the use of a oscillopsia and a feeling of tremor in her left eye. topical ,1 blocker in one patient.4 The symptoms occurred periodically and were Betaxolol has weak membrane stabilising particularly troublesome when she was reading. effects compared with other 1i blockers and is On examination, visual acuity was 6/6 unaided. unlikely to work topically. However, it has a Anterior segments, pupil reflexes, and fundu- bioavailability of 89% and demonstrates signific- scopy were unremarkable. Lid position was ant reduction in finger tremor when adminis- normal and she had a full range of ocular tered parenterally.5 We hypothesise that enough movements. Slit-lamp biomicroscopy disclosed a betaxolol may be absorbed systemically to cyclotorsional tremor of fine amplitude with a eliminate SOM. The drug is cardioselective and vertical element. This was intermittent but could has fewer of the side effects associated with be induced by her looking down and to the right. propranolol or carbamazepine. It may be of use We prescribed betaxolol drops twice daily to as a first line treatment in those patients whose the left eye for 1 month, and reviewed the woman symptoms are intolerable. Leicester Royal Infirmary after 2 months. In the 4 weeks she had been using the 1 Hoyt WF, Keane JR. Superior oblique myokymia. Arch K Bibby drops she had been asymptomatic, but her Ophthalmol 1970; 84: 461-7. J S Deane problem returned within 1 week of stopping 2 Susac JO, Smith JL. Superior oblique myokymia. Arch Neurol D Farnworth treatment. 1973; 29: 432-4. J Cappin On examination left SOM was 3 Tyler TD, Ruiz RS. Propranolol in the treatment of superior apparent. She Correspondence to: recommenced topical betaxolol oblique myokymia. Arch Ophthalmol 1990; 108: 175-6. Kim Bibby, Department of and when reviewed at 3 and 6 months was totally 4 Leigh JR, Tomsak RL, Seidman MS, Dell'Osso LF. Superior Ophthalmology, Leicester oblique myokymia. Quantitative analysis of the eye move- Royal Infirmary, Leics LEI. asymptomatic. No SOM was observed on six ments in three patients. Arch Ophthalmol 1991; 109: 1710-3. separate two 5 Irvine NA, Lipworth BJ, McDevitt DG. A dose-ranging study Accepted for publication occasions during these outpatient to evaluate the beta-adrenoceptor selectivity ofsingle doses of 14 June 1994 appointments. betaxolol. BrJ7 Pharmacol 1990; 30: 119-26. Notices. Corrections 197

memory of Professor Michaelson - will be After data checking and a repeat analysis held in Budapest, Hungary on 22-26 May they have found 14 individuals who had been NOTICES 1995. Further details: Congress Bureau incorrectly classified as blind since they had Motesz, Budapest, Hungary, PO Box 145, seen one or more Friedmann test points at H-1443. 100 or more in the better eye. Although these corrections do not change substantially the pattern and prevalence Photonics West '95 Vth International Symposium on figure, they do alter to an important degree Sjogren's Syndrome the visual field constriction data. In view of The International Society for Optical the rarity of data on this topic the authors Engineering (SPIE) will hold a conference The Vth International Symposium on feel that it is important to correct their entitled 'Photonics West '95' on 4-10 Sj6gren's syndrome will be held on 15-17 report. They originally reported 42 individu- February 1995 at the San Jose Convention June 1995, in Noordwijkerhout, the Nether- als to be blind by visual field constriction (a Center, San Jose, California, USA. This lands. Further details from: Conference prevalence of 0 6%). The correct figure for meeting consolidates three established secretariat: A A Kruize, Department of blindness by visual field constriction is now California meetings, OE/LASE, Biomedical Rheumatology F02.223, University Hospital 28 individuals (0 4%). Three of those previ- Optics, and the IS&T/SPIE Symposium on Utrecht, p/o Box 85500, 3508 GA, Utrecht, ously classified as blind by visual field con- Electronic Imaging Science and Technology. the Netherlands. (Tel: +31 30 507357; Fax: striction are now classified as visually Further details: SPIE, PO Box 10, +31 30 523741.) impaired by acuity criteria, and a further Bellingham, WA 98227-0010, USA. (Tel: three are now classified as unilaterally blind. 206/676-3290; Fax: 206/647-1445.) Eight individuals are now classified as International Society for Clinical sighted. The table below gives pinhole acuity Electrophysiology ofVision and cause of ocular pathology for each eye in British College of Optometrists the 14 individuals concerned. The 33rd ISCEV symposium will be held in A revised version of the abstract published The centenary conference of the British Athens, Greece, 16-20 June 1995. The con- with the paper, corrected to take account of College of Optometrists will be held at gress is organised by the International Society these changes, is given below. The authors Churchill College, Cambridge on 5-8 April for Clinical Electrophysiology of Vision. apologise for this correction. Further details 1995. Further details: BCO Conference Further details: Secretariat, Erasmus of their visual field findings will be published Secretariat, Conference Contact, 42 Conference Centre, International Congress shortly. Devonshire Road, Cambridge CB1 2BL. Organisers, 227 Kifissias Ave, 145 61 Kifissia, (Tel: 01223 323437; Fax: 01223 460396.) Greece. (Tel: (01) 6125022/3, 8054004; Fax: Revised abstract (01) 6125021.) During a field trial of ivermectin, 6831 people age 5 years and above living in 34 1st International Conference on Ocular mesoendemic onchocercal communities in Aspects of Marfan's Disease Kaduna State, northern Nigeria, were Corrections examined for ocular disease. Visual function The first international conference on ocular assessments included tests of visual acuity aspects of Marfan's disease will be held at the We regret that there was an error in the and visual fields. 185 individuals (2 7%) University of Munster, Germany on 8 April paper by R M Manners and J R 0 Collin that were bilaterally blind by acuity criteria 1995. Further details: H Gerding, H Busse, C appeared in the November issue of the jour- with a further 28 blind by field constriction. Schroeter, Marfan Conference, Postfach nal (1994; 78: 881-2). Figures 1 and 2 were The overall prevalence of blindness was 2322, 59013 Hamm, Germany. (Tel: 0049 reversed but the captions were correct. 3-1%. A further 118 individuals were 2381-271746; Fax: 0049-2381-271743.) Figure 2 showed a preoperative appearance visually impaired by WHO criteria. of the patient and Figure 1 a postoperative Examination for the cause of blindness picture. revealed that 43% of eyes in bilaterally blind United Kingdom Transplant Support patients were blind due to onchocerciasis. A Service Authority further 11% were blind from optic atrophy The authors (Abiose et al) wish to make a much of which is probably onchocercal in There will be a 'Corneal Transplant Meeting' correction to their blindness data' presented origin. Glaucoma was the next most com- on 10 April 1995 to be held at the in the paper that appeared in the January mon cause of blind eyes in the bilaterally Postgraduate and Health Sciences Building, issue of the journal (1994; 78: 8-13). Since blind (11%). Only 6% of eyes were blind Central Manchester Trust. Further details: the manual analysis of visual field data set, from cataract as the primary cause. In the Julia Warren, UK Transplant Support Service which resulted in their presentation of data visually impaired population cataract was Authority, Fox Den Road, Stoke Gifford, on those blind by virtue of visual field con- the most common primary cause of Bristol BS12 6RR. (Tel: 0117 9757555; Fax: striction, they have now entered the impaired/blind eyes (31%), followed by 0117 9757577.) Friedmann field data onto microcomputer. onchocerciasis (19%).

Association for Research in Vision and Ophthalmology Acuity Pathology Acuity Pathology Patient right right left left Comment The annual meeting of the Association for 1 6/36 Onchocerciasis PL Chronic inflammatory Reclassify as visually Research in Vision and Ophthalmology disease impaired (ARVO) will be held on 14-19 May 1995 at 2 6/36 Onchocerciasis 6/36 Onchocerciasis Reclassify as visually the Fort Lauderdale/Broward County impaired 3 6/36 Onchocerciasis PL Onchocerciasis Reclassify as visually Convention Center, Fort Lauderdale, impaired Florida, USA. Further details: Anne Meltzer, 4 NPL Trachoma 6/9 Optic atrophy Reclassify as the ARVO Central Office, 9650 Rockville unilaterally blind MD USA. 5 6/18 Onchocerciasis PL Onchocerciasis Reclassify as Pike, Bethesda, 20814-3998, unilaterally blind (Tel: (301) 571-1844; Fax: (301) 6 6/9 Onchocerciasis NPL Onchocerciasis Reclassify as 571-8311.) unilaterally blind 7 6/60 Glaucoma 6/9 Glaucoma Reclassify as sighted 8 6/18 Optic atrophy 6/18 Optic atrophy Reclassify as sighted 9 6/36 Onchocerciasis 6/9 Onchocerciasis Reclassify as sighted 4th International Symposium on Ocular 10 6/9 Retinitis pigmentosa 6/18 Retinitis pigmentosa Reclassify as sighted Circulation and Neovascularisation 11 6/9 Onchocerciasis 6/9 Onchocerciasis Reclassify as sighted 12 6/9 Optic atrophy 6/9 Optic atrophy Reclassify as sighted 13 6/9 Optic atrophy 6/9 Optic atrophy Reclassify as sighted The 4th International Symposium on Ocular 14 6/9 Onchocerciasis 6/9 Onchocerciasis Reclassify as sighted Circulation and neovascularisation - in